Case 1: Large-volume GI bleeding
A 52-year-old man is brought to the emergency department after vomiting several cups of maroon-colored blood. After he awoke this morning, he developed epigastric fullness and nausea followed by vomiting. He is otherwise well, and his only medication is a daily low-dose aspirin tablet.
Physical examination discloses tachycardia and a mild orthostatic decrease in blood pressure. The hemoglobin level is 9.6 g/dL (96 g/L) (baseline value, 13.4 g/dL [134 g/L]). Blood transfusions are begun. Emergent upper endoscopy shows copious clots and fresh and old blood throughout the stomach and duodenum. A specific lesion is not identified.
The patient is hospitalized. Following blood transfusions, his hemoglobin level increases to 11.4 g/dL (114 g/L), and he becomes asymptomatic.
On the second hospital day, repeat upper endoscopy shows several small erosions in the gastric antrum and duodenal bulb. There is also mild erythema at the gastroesophageal junction, suggesting reflux esophagitis. A CT scan of the abdomen is normal.
Which of the following diagnostic studies should be performed next?
A. Small bowel follow-through radiographic studies
B. Capsule endoscopy (capsule enteroscopy)
C. Mesenteric angiography
D. Tagged red blood cell scan
E. No further diagnostic testing at this time
Case 2: Bleeding with abdominal pain and fever
A 72-year-old woman is brought to the emergency department after having vomited a large amount of blood. She has had mild upper abdominal pain and low-grade fevers for several weeks. Medical history is significant for systolic hypertension and repair of an abdominal aortic aneurysm. Current medications are simvastatin, metoprolol, hydrochlorothiazide and low-dose aspirin.
On physical examination, she is pale, clammy and weak. Temperature is 38.2 °C (100.8 °F), pulse rate is 105 beats/min and blood pressure is 85/60 mm Hg supine. Abdominal examination shows mid-epigastric tenderness without guarding or rebound. Bowel sounds are hyperactive. Rectal examination reveals black, tarry stool that is positive for occult blood.
Laboratory studies show a hemoglobin level of 10.9 g/dL (109 g/L), a leukocyte count of 13,400 cells/µL (13.4 × 109 cells/L), a blood urea nitrogen level of 40 mg/dL (14.28 mmol/L) and a serum creatinine concentration of 1.2 mg/dL (106.1 μmol/L).
Volume resuscitation is begun, and upper endoscopy is performed. Although the study is normal, the patient states that her abdominal pain is becoming more intense.
Which of the following diagnostic studies should be done next?
A. Contrast-enhanced CT scan of the abdomen
C. Small bowel follow-through radiographic study
D. Abdominal ultrasonography
E. Red blood cell scan
Case 3: Hematemesis
A 48-year-old man with a long history of alcohol abuse is brought to the emergency department for evaluation of hematemesis. He has no other known medical problems, takes no medications and has never established regular care with a physician.
On physical examination, the patient is obviously intoxicated and can barely be roused. Pulse rate is 115 beats/min and blood pressure is 80/49 mm Hg. Spider angiomata are present. Abdominal examination discloses a firm liver edge and splenomegaly. Intravenous fluids are begun, but before blood samples are drawn for laboratory studies, the patient vomits a profuse amount of bright red blood.
Which of the following is the most appropriate management at this time?
A. Intravenous β-blocker therapy
B. Upper endoscopy
C. Red blood cell transfusion
D. Endotracheal intubation
E. Transjugular intrahepatic portosystemic shunt (TIPS)
Case 4: Intermittent rectal bleeding
A 51-year-old woman has a three-month history of intermittent rectal bleeding and pain on defecation. Bloody streaks cover the stool, and the toilet paper is also bloody. She is otherwise well and takes no medications.
One month before the bleeding developed, she underwent laminectomy for a herniated lumbar disc and required narcotic drugs for several weeks postoperatively. The narcotics caused significant constipation that improved on a high-fiber diet. The patient had her first screening colonoscopy less than one year ago, which showed a diminutive hyperplastic polyp in the rectosigmoid colon and a few sigmoid diverticula. A retroflexed view of the rectum revealed small internal hemorrhoids.
Rectal examination today demonstrates tenderness in the anal canals, small external hemorrhoids and several anal skin tags. The hemoglobin level is 13.9 g/dL (139 g/L).
Which of the following is most likely causing this patient's rectal bleeding?
A. An anal fissure
B. Rectal cancer
Case 5: Periumbilical abdominal pain and hematochezia
A 23-year-old man is evaluated because of periumbilical abdominal pain and hematochezia. Four months ago, he was hospitalized because of a similar episode. At that time, his hemoglobin level was 10.8 g/dL (108 g/L), and blood transfusions were not required. Results of upper endoscopy, colonoscopy with intubation of the terminal ileum and capsule endoscopy (capsule enteroscopy) were normal, and he was discharged after several days of observation.
The patient remained asymptomatic until two days ago, when the periumbilical abdominal pain recurred. Last night, he had another episode of hematochezia.
On physical examination this morning, he appears anxious but in no acute distress. He has not had a bowel movement since last evening. Vital signs and general examination are normal, and his hemoglobin level is 9.8 g/dL (98 g/L).
Which of the following diagnostic studies should be performed next?
A. Extended upper endoscopy
B. Tagged red blood cell scan
C. Meckel's scan
D. Repeat capsule endoscopy
E. Intraoperative endoscopy
Answers and commentary
Correct answer: E. No further diagnostic testing at this time.
This patient has large-volume upper gastrointestinal bleeding with only minor mucosal abnormalities identified on upper endoscopy. This presentation is typical for a gastric Dieulafoy lesion, which is an abnormally large artery located just below the mucosa, where it is prone to rupture and cause large-volume bleeding. No additional diagnostic studies are indicated at this time. However, urgent repeat upper endoscopy is needed if there is any evidence of recurrent bleeding.
Small bowel follow-through radiographic studies and capsule endoscopy are useful for evaluating sources of bleeding in the small bowel. However, a small bowel source of bleeding is unlikely in this patient with hematemesis and significant blood in the stomach on initial upper endoscopy. He is currently stable, and there is no evidence of ongoing bleeding. Therefore, results of mesenteric angiography and a tagged red blood cell scan are likely to be normal.
- A Dieulafoy lesion is an abnormally large artery located just below the gastric mucosa that is prone to rupture and cause large-volume bleeding.
Correct answer: A. Contrast-enhanced CT scan of the abdomen.
Upper gastrointestinal bleeding, abdominal pain and features of an underlying infection (fever, leukocytosis) in a patient with a known abdominal prosthetic vascular graft should raise concern about the presence of an aortoenteric fistula. Aortoenteric fistulas often arise from the distal duodenum and may be caused by an atherosclerotic aortic aneurysm or an infected prosthetic graft. Patients initially develop hematemesis, melena or hematochezia, which may be followed by massive bleeding, and may also have fever and back and abdominal pain.
Upper endoscopy is the procedure of choice for diagnosis and to exclude other causes of acute upper gastrointestinal bleeding. If upper endoscopy is normal despite a strong clinical suspicion for an aortoenteric fistula, a contrast-enhanced CT scan of the abdomen may reveal air or fluid around the aneurysm or graft with thickening of the adjacent bowel wall and possibly extravasation of contrast. An emergent surgical consultation should be obtained for repair of the fistula, as delay in treating this condition is associated with a very high mortality rate.
Because this patient's clinical features are highly suggestive of an aortoenteric fistula, colonoscopy would not provide useful information, and the time needed for the associated bowel preparation would delay definitive therapy. A small bowel follow-through radiographic study is not useful in the evaluation of hematochezia and would further delay definitive diagnosis and treatment. Abdominal ultrasonography is helpful for detecting a possible abdominal aneurysm but has low sensitivity for diagnosing a suspected aortoenteric fistula. A red blood cell scan is used to evaluate a patient with obscure gastrointestinal bleeding and would be premature in this patient.
- Gastrointestinal bleeding, fever, abdominal pain and leukocytosis in a patient with an abdominal prosthetic vascular graft should raise suspicion for an aortoenteric fistula.
- Upper endoscopy is the initial diagnostic study for evaluation of a possible aortoenteric fistula.
- If results of upper endoscopy are normal despite a strong clinical suspicion for an aortoenteric fistula, a contrast-enhanced CT scan of the abdomen should be done next.
Correct answer: D. Endotracheal intubation.
This patient most likely has bleeding gastroesophageal varices based on his history of alcohol abuse and his physical examination findings. Regardless of the cause of the bleeding, however, the patient is intoxicated and can barely be roused, and protection of his airway with endotracheal intubation is paramount. All patients with acute gastrointestinal bleeding associated with a decreased level of consciousness, absent gag reflex and continued hematemesis require airway protection.
Although nonselective β-blocker therapy should be considered for both primary therapy and secondary prevention of bleeding in patients with cirrhosis and esophageal varices, initiating a β-blocker is inappropriate in a patient with acute bleeding and hypotension. Upper endoscopy is indicated once a patient is hemodynamically stable in order to determine if the bleeding lesion can be treated with endoscopic therapy. Although this patient may need a transfusion as part of the resuscitation process, airway protection must be done first. A transjugular intrahepatic portosystemic shunt (TIPS) may be needed if the bleeding cannot be controlled with medical and endoscopic therapy but is inappropriate as initial treatment.
- Patients with acute gastrointestinal bleeding associated with decreased consciousness, an absent gag reflex and continued hematemesis require airway protection as the initial step in management.
Correct answer: A. An anal fissure.
This patient most likely has an anal fissure that is causing rectal outlet bleeding and pain with defecation and that is probably due to her recent constipation. Careful rectal examination may reveal the fissure, but this finding may not always be apparent without use of an anoscope.
Rectal cancer must always be considered in someone with new-onset rectal outlet bleeding. However, this patient underwent colonoscopy less than one year ago, which showed only a diminutive hyperplastic polyp. When evaluating a patient for a possible neoplasm, the endoscopist should always attempt to do a retroflexed view of the rectum in order to exclude a distal rectal cancer.
Although this patient has diverticula, the fact that her bleeding occurs with defecation and has been present over a three-month period is not typical of diverticular bleeding, which tends to cause significant acute hematochezia that often stops spontaneously. Hemorrhoidal bleeding is also a plausible explanation for this patient's symptoms because of the small hemorrhoids noted on prior colonoscopy and on rectal examination and the recent constipation. However, hemorrhoidal bleeding is most often associated with painless defecation. Angiectasia-related bleeding typically results from lesions in the cecum and proximal colon, is painless, and tends to cause bleeding episodes that are unrelated to defecation.
- Anal fissures generally cause rectal outlet bleeding and pain with defecation.
- Anal fissures may occur after a period of constipation.
Correct answer: C. Meckel's scan.
This patient has had a second episode of acute gastrointestinal bleeding in four months. Initial diagnostic studies, including upper endoscopy, did not identify a bleeding source. Because of the patient's young age and periumbilical pain, he may have a Meckel's diverticulum, and a radionuclide study (Meckel's scan) should be done next. If the results of this study are normal, repeat capsule endoscopy should be considered.
Extended upper endoscopy, in which a longer endoscope is used to intubate the small bowel beyond the duodenum, is sometimes helpful in determining the cause of obscure gastrointestinal bleeding. However, this study has a higher yield in older patients who are more likely to have angiectasias. A tagged red blood cell scan requires active bleeding and is therefore unlikely to be diagnostic in this patient, who is hemodynamically stable and does not have evidence of ongoing bleeding.
Although intraoperative endoscopy has the highest yield for identifying a source of small bowel bleeding, it is an invasive procedure and is indicated only if other less invasive studies are nondiagnostic.
- The age of a patient with obscure gastrointestinal bleeding helps guide the choice of diagnostic studies to be performed.
- A young patient with obscure gastrointestinal bleeding should undergo diagnostic studies for Meckel's diverticulum.
- An older patient with obscure gastrointestinal bleeding should undergo studies for angiectasias.